PIPELINE TEST REPORT

(PRESSURE TEST)

OPERATING COMPANY:

Testing Company:

This form must be completed for each section of newly installed section of pipe or service
line and on each service line that is disconnected from the main for any reason.

Test Data

Type of Pipe:
Size of Pipe: inches Length of Line:
Location of Line:

Tested with: Nitrogen ( ) Air ( ) Natural Gas ( ) Water ( )

Other (describe):
Time Started: _______________a.m./p.m. Time Ended: _________________ a.m./p.m.
Test Pressure Start: psig
Test Pressure Stop: psig
Line Loss: Yes No Amount Loss: mcf
Reason for Line Loss:

Corrective Measures Taken:

Remarks:

Company Representative:
Signature: Date: